[PD Test]Individualizing asthma treatment: When to step up or step down?

The variability of asthma between individual patients provides a strong rationale for the routine use of step up/step down therapy in asthma management, an expert says.

“Stepping up and stepping down asthma treatment is a necessary part of asthma management,” surmised Dr. Peter Gibson, senior staff specialist physician, Department of Respiratory and Sleep Medicine, John Hunter Hospital, New South Wales, Australia. “It allows the doctor to provide optimal drug dosing for disease control while minimizing drug exposure and the potential for adverse effects.”

Gibson listed four different approaches to stepping up/down therapy: (1) step up/down based on asthma control assessments, eg, Global Initiative for Asthma (GINA) guidelines; (2) step up/down based on asthma control measures used in combination with inflammatory markers, eg, inflammometry based on fraction of exhaled nitric oxide (FeNO) or induced sputum; (3) variable dosing based on patient perceived symptom recognition; and (4) step up/down based on recognition of a particular phenotype.

The first approach forms the basis of GINA guidelines and relies on an assessment of asthma control linked to a drug dose or class adjustment. The available assessment methods include asthma control questionnaire (ACQ), the asthma control test (ACT), and measures of symptom frequency. Each assessment method has been shown to produce good results – the benefits achieved with this approach are a significant reduction in asthma exacerbations and an increased likelihood of achieving symptom control.

The second approach, which involves the use of inflammometry, has been shown to reduce episodes of severe asthma exacerbations by up to half compared with guideline-based therapy. Sputum eosinophilia serves as a marker of the corticosteroid responsive component of asthma. When it is present, it indicates that the patient requires a higher dosage of corticosteroid.

Customizing doses based on perceived asthma symptom frequency is also a highly efficacious approach leading to a reduced exacerbation frequency. With this approach, patients themselves can adjust their dose of inhaled corticosteroid/long-acting beta-agonist (ICS-LABA).

Finally, step up/down using phenotype-based therapy, whereby the recognition of a particular phenotype leads to improved selection of appropriate drug class and dosage level for the patient. However, Gibson added that presently there are limited data to support this approach.